Anaesthesia and intensive care
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Anaesth Intensive Care · May 2017
ReviewEndothelial glycocalyx: basic science and clinical implications.
The classic Starling principle proposed that microvascular fluid exchange was determined by a balance of hydrostatic and oncotic pressures relative to the vascular wall and this movement of water was regulated by gaps in the intercellular spaces. However, current literature on the endothelial glycocalyx (a jelly-like protective layer covering the luminal surface of the endothelium) has revised Starling's traditional concepts. ⋯ Pathological shedding of the glycocalyx occurs in response to mechanical cellular stress, endotoxins, inflammatory mediators, atrial natriuretic peptide, ischaemia-reperfusion injury, free oxygen radicals and hyperglycaemia. Increased understanding of the endothelial glycocalyx may change perioperative fluid management, and therapeutic strategies aimed at its preservation may improve patient outcomes.
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Anaesth Intensive Care · May 2017
Coming full circle: thirty years of paediatric fluid resuscitation.
Fluid bolus therapy (FBT) is a cornerstone of the management of the septic child, but clinical research in this field is challenging to perform, and hard to interpret. The evidence base for independent benefit from liberal FBT in the developed world is limited, and the Fluid Expansion as Supportive Therapy (FEAST) trial has led to conservative changes in the World Health Organization-recommended approach to FBT in resource-poor settings. ⋯ Such trials could examine differing strategies of fluid resuscitation, or compare early FBT to early vasoactive agent use. Given the ubiquity of FBT and the potential for harm, appropriately powered examinations of the efficacy of FBT compared to alternative interventions in the paediatric emergency and ICU settings in the developed world appear justified and warranted.
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Anaesth Intensive Care · May 2017
A survey of Australian and New Zealand anaesthetists' attitudes towards resuscitation orders in the perioperative setting.
Not for resuscitation (NFR) orders are often suspended during anaesthesia, as perioperative care is believed to inherently involve the need for resuscitation including ventilation support. Recent legislative changes in Australia, New Zealand and the UK have enacted the binding nature of advance care directives (ACDs) in healthcare. National guidelines regarding codes of practice and government strategic plans for implementing advance care planning have reinforced the role for advance care planning in modern healthcare. ⋯ Over 90% reported that patient's wishes and understanding of ACDs is important and 89% agreed or strongly agreed that advance care planning should be a routine part of hospital admission for high risk patients. Despite this, only 45% of the respondents would always follow an ACD. Although the majority of respondents to this survey support their use in the perioperative setting, clarification of the specific applicability of ACDs to anaesthesia and their binding nature is required.
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Anaesth Intensive Care · May 2017
Multicenter StudyRelationship between functional status prior to onset of critical illness and mortality: a prospective multicentre cohort study.
This prospective study aimed to assess the association between prior functional status and hospital mortality for patients admitted to four intensive care units in Spain between 2006 and 2012. Prior functional status was classified into three groups, using a modification of the Glasgow Outcome Scale (GOS), including group 1 with no limitations on activities of daily living; group 2 with some limitations but self-sufficient; and group 3 who were dependent on others for their activities of daily living. Of the 1,757 patients considered (mean Simplified Acute Physiology Score [SAPS] predicted mortality 14.8% and hospital mortality 13.7%), group 1 had the lowest observed hospital mortality (8.3%) compared to the SAPS 3 predicted mortality (11.6%). ⋯ Combining prior functional status and Sequential Organ Failure Assessment (SOFA) score with SAPS 3 further improved the ability of the SAPS 3 scores in predicting hospital mortality (area under the receiver operating characteristic curve 0.85 [95% CI 0.82-0.88] versus 0.84 [95% CI 0.81-0.87] respectively). In summary, patients with limited functional status prior to ICU admission had a higher risk of observed hospital mortality than predicted. Assessing prior functional status using a relatively simple questionnaire, such as a modified GOS, has the potential to improve the accuracy of existing prognostic models.